Childhood obesity is a problem nationwide. The Centers for Disease Control and Prevention reports that obesity among children aged 6 to 11 years increased more than threefold in three decades. In 2008, 19.6 percent of kids in that age group were obese, up from 6.5 percent in 1980.
In Tennessee's Appalachian communities, the problem is compounded by poverty, poor nutrition education and a tradition of foods loaded with fat and sugar. "Children facing those hurdles to a healthy lifestyle are more likely to suffer from cardiovascular disease, type 2 diabetes and bone and joint problems as adults," said Jill Beason, regional director of community services for Mercy Health Partners in Knoxville, Tenn.
"Our caregivers are seeing heart problems in younger and younger adult patients," said Beason. "There is a huge focus on management of chronic disease. We said to ourselves, 'Let's not manage it. Let's prevent it.'"
To begin to identify and address risk factors for diet-related disease, Mercy Health Partners launched C.A.R.D.I.A.C. Kids. The acronym is short for Coronary Artery Risk Detection in Appalachian Communities. The program is modeled after one developed in West Virginia by Dr. William Neal, a pediatric cardiologist and professor of medicine at West Virginia University.
The Tennessee program, which began in 2004, has screened over 2,500 fourth and fifth graders. It operates in six East Tennessee counties, and this school year Mercy is expanding it into a seventh.
C.A.R.D.I.A.C. Kids staff run clinics at schools where they calculate students' body mass index. They measure blood pressure; high density lipoprotein, known as HDL; and total cholesterol and glucose. Screeners also look for acanthosis nigricans, a skin disorder associated with diabetes. Both the school nurse and the parents receive test results. Parents also get information on disease prevention. Parents and doctors of students identified as "high risk" receive a "call to action," and those students receive further screening tests.
Sausage, biscuits and gravy
Beason is dismayed, but not surprised, by the results to date. Some 20 percent of participating children have high cholesterol, and 40 percent are overweight. Of those students, 40 percent are obese.
"One of the first questions we ask kids is, 'What did you have for breakfast?' And the answer is sausage, biscuits and gravy," Beason said. "We have our own shorthand for it — SBG. In a lot of schools, that's what is served. It's the culture, although we are making some slow headway in convincing some schools to serve healthier foods." The increased focus nationally on improving nutrition in schools is helping to raise awareness, she said.
Even more disconcerting is the 80 percent of parents who do not consent to the screening for their children.
"The percentage of participating students is nowhere where it needs to be," said Beason. "I wouldn't want to say it's apathy, but maybe denial is a better word — 'I don't want to face the outcome.'"
Still, Beason is hopeful. Three years ago Tennessee embraced the CDC-endorsed Coordinated School Health strategy for improving health education. As part of that commitment, the state assesses the health status of children in the second, fourth, sixth and eighth grades. Schools where more than 35 percent of the student body is either overweight or obese are considered "at risk."
Schools that meet the C.A.R.D.I.A.C. Kids at-risk criteria and that are headed by administrators committed to health education, may be candidates for the C.A.R.D.I.A.C. Club program, Beason said.
After-school lessons
In 2009, Beason teamed up with the director of the Knox County Coordinated School Health program and the University of Tennessee Extension, the university's college of nursing and its nutrition department, to take the C.A.R.D.I.A.C. Kids program one step further. They developed and launched C.A.R.D.I.A.C. Club at Adrian Burnett Elementary School. Kids apply to attend the 10-week, after-school program by writing an essay. There are slots for 40 fourth and fifth grade students, and so far there has been space to take all comers. The program, now offered twice a year, teaches kids and their parents to make behavior changes that can lower health risks.
In 2009, when the after-school program began there, an alarming 44 percent of fourth and fifth graders were obese. Not all the participants in the C.A.R.D.I.A.C. Club are overweight, though; some of them are underweight. One can be overweight or underweight and be malnourished. "That's why education about nutrition is so important," Beason said.
So far, eight out of 10 children screened by C.A.R.D.I.A.C. Kids have had at least one parent whose smoking, weight or family history of heart disease put the adult at risk for heart problems, Beason said. The C.A.R.D.I.A.C. Club curriculum gives presenters a shot at changing parental behavior too. Parents must commit to attend two health education workshops.
Students in C.A.R.D.I.A.C. Club meet twice a week in 90 minute sessions to exercise, enjoy a healthy snack and play games that teach them about nutrition and fitness.
"This program has been great for a lot of reasons," said Beason. "A dad came up to me, and he said, 'We have committed to trying two new foods a month.' School personnel report that kids who typically wouldn't be involved in athletics find new friends and get active. Those are the things that are hard to measure, but they are changes that hopefully last a lifetime."
Beason concedes it's difficult to measure outcomes since students grow so fast during fourth and fifth grade. However, BMI has dipped slightly and fitness levels have improved among many participants. Beason said sponsors are assessing data and continue to refine the program.
This fall, the sponsors are bringing the after-school program to a second elementary school in Knoxville. They are considering starting a middle school program that would enroll children in the seventh and eighth grades. "There's less parental control and more independence about food choices at that age," Beason said.
The University of Tennessee Department of Nutrition has applied for a U.S. Department of Agriculture grant to bring the after-school program to rural schools.
Pencils, not candy
In her 31 years as an educator, Adrian Burnett Elementary' s Principal Kathy Duggan had noticed students getting heavier, and she was eager to stop the school's role in this disturbing trend when she welcomed the after-school nutrition program.
Duggan has banned sugary snacks from school parties. She encourages families to keep candy bars and potato chips out of lunch boxes. Duggan said she got a lot of parental push-back at first, but now they know to bring pencils or games for school parties, not brownies and candy.
She also wanted to make sure the school serves healthier foods. Some two-thirds of school's 675 students qualify for the federal free and reduced-cost lunch program, so what the school puts on the cafeteria line for breakfast and lunch has a direct impact on the students' daily diet.
Lessons learned in the fourth and fifth grade though C.A.R.D.I.A.C. Kids and C.A.R.D.I.A.C. Club are trickling down to younger students. "We used to see a lot of vegetables in the trash. Now kids are actually choosing to eat salads," Duggan said, and many younger kids are excited about joining C.A.R.D.I.A.C. Club.
Duggan is confident the school's small victories will one day add up to big changes for the health of her students.
"The program served as a springboard to other healthy initiatives, such as our school having a huge number of entries at last year's Run for the Schools, ensuring our Field Days were junk food-free, and a yearly fund-raiser that encourages our entire community to walk a mile," said Duggan.
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